JAMES PITTMAN
University of California San Diego, VA San Diego Center of Excellence for Stress and Mental Health

Post-9/11 veterans who enroll in VA health care frequently present with suicidal ideation and/or recent suicidal behavior. Most of these veterans are not screened on their day of enrollment and their risk goes undetected. Screening for suicide risk, and associated mental health factors, can lead to early detection and referral to effective treatment thereby decreasing suicide risk. eScreening is an innovative Gold Standard Practice with evidence to support its effectiveness and implementation potential in transition and care management (TCM) programs. We will evaluate the impact of eScreening to improve rate and speed of suicide risk screening and referral to mental health care compared to current screening methods used by transition care managers. We will also evaluate the impact of an innovative, multicomponent implementation strategy (MCIS) on the reach, adoption, implementation, and sustained use of eScreening.

eScreening will be implemented in eight VA healthcare systems focused on screening Post 9/11 veterans enrolling in TCM.

This is an eight site, four year, stepped-wedge, mixed-method, hybrid type-II implementation/pragmatic trial comparing eScreening to screening as usual while also evaluating potential impact of the MCIS focusing on external facilitation and Lean/SixSigma rapid process improvement workshops in TCM. The aims will address: 1) whether using eScreening compared to oral and/or paper based methods in TCM programs is associated with improved rates and speed of PTSD, depression, alcohol, and suicide screening & evaluation, and increased referral to mental health treatment; 2) whether and to what degree our MCIS is feasible, acceptable, and has the potential to impact adoption, implementation, and maintenance of eScreening; and 3) how contextual factors influence the implementation of eScreening between high and low eScreening adopting sites. We will use a mixed methods approach guided by the RE-AIM outcomes of the Practical Robust Implementation and Sustainability Model (PRISM). Data to address Aim 1 will be collected via medical record query while data for Aims 2 and 3 will be collected from TCM staff questionnaires and qualitative interviews.

The results of this study will help identify best practices for screening in suicide prevention for Post-9/11 veterans enrolling in VA health care and will provide information on how best to implement technology-based screening into real world clinical care programs.

ANJU SAHAY, PhD
Veterans Affairs Palo Alto Health Care System

The focus of the Department of Veteran Affairs’ (VA) Medication Safety (MedSafe) QUERI Program is to reduce potentially unsafe or unnecessary medications for Veterans. We conducted the national evaluation on the utilization of the VA Office of Pharmacy Benefits Management (PBM) Service’s Center for Medication Safety (VAMedSAFE) Web application called the Medication Use Evaluation Tracker (MUET). On a monthly/quarterly basis this application identifies at-risk Veterans across all VA sites.
 
Our national evaluation confirmed interest in PBM/VAMedSAFE development of national medication safety and appropriate use of dashboards to identify and reduce potentially unsafe medication utilization. The Direct Oral Anticoagulant (DOAC) patient management tool was developed as a facility/VISN initiative and was evaluated as a candidate for national use based on the occurrence of adverse events and risk of therapeutic failures related to DOAC therapy. VAMedSAFE validated and optimized the report with the developer, and in conjunction with our MedSafe QUERI Program the DOAC Dashboard became the first national medication safety dashboard.

Development of five national dashboards.

In September 2017 in conjunction with PBM, the MedSafe QUERI Program invited subject matter experts, VISN (Regional) Pharmacy Executives and other key stakeholders to form the PBM VAMedSAFE National Medication Safety Dashboard Advisory Committee. The role of this Committee has been to coordinate and approve dashboard solutions that relate to VAMedSAFE national projects and initiatives. This Committee meets on a quarterly basis and has prioritized the development or adoption of five National Dashboards as mediation safety/appropriate use population health management tools. These dashboards are designed to identify at-risk Veterans across all the VA sites with regular data updates and daily accessibility to clinicians.

In July 2019, the DOAC Dashboard was made available at all 146 VA sites (18 VISNs) for the monitoring of all patients prescribed DOAC therapy. By December 2020, the DOAC Dashboard use has been documented at 122 (84%) sites where staff at these sites have utilized the DOAC Dashboard to complete at least one write-back (an administrative marker for the use of this Dashboard).
 
At these 122 (84%) sites, a total of 1,500 staff have previously and/or currently use the DOAC Dashboard. In contrast, as yet no write-back has been received from the remaining 24 (16%) sites. This Dashboard has already served a total of 173,918 Veterans.
 
The remaining four dashboards at various stages of development are: Proton Pump Inhibitors Dashboard, AntiCD20 Antibody Dashboard, Direct-Acting Antivirals-Hepatitis B Monitoring/Re-activation Dashboard andAzathioprine/6-Mercaptopurine Dashboard.

As a population health management tool, the DOAC Dashboard provides oversight for the monitoring of treatment for DOACs.